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CAPNOGRAPHY : 2002; 46 (4) : 269-278 Indian J. Anaesth.

DMELLO, BUTANI

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CAPNOGRAPHY
Dr. Jacqueline DMello1 Dr. Manju Butani2 SUMMARY
Capnography, has become an integral part of monitoring in anaesthesia and helps to prevent life threatening events. Monitors use infrared spectrography, mass spectrography, Raman spectrography, photoacoustic analysers or colorimetric devices to measure carbon dioxide in the respiratory gases and then give a numerical reading (capnometry) and a waveform (capnography). There are two types of capnographs: mainstream and side stream. The capnogram or waveform gives us information about inspiration and expiration as well as the arterial to end tidal carbon dioxide differences. Clinically respired carbon dioxide reflects changes in metabolism, circulation, respiration, the airway and the breathing system. Thus capnography as a monitoring tool has come to stay, and a detailed study of the waveforms and their interpretation has now become mandatory.

Keywords : Capnography, capnometer, capnogram; anaesthesia, monitoring Introduction Capnography, the measurement of CO 2 in respiratory gases has become an integral part of anaesthesia monitoring. Luft developed the principle of capnography in 1943 from the knowledge that CO2 is one of the gases that absorbs infra-red (IR) radiation of a particular wavelength. The accuracy of rapid IR CO2 analysis in determining alveolar carbon dioxide concentration was established by Collier and his colleagues and the value of the end tidal sample established by Ramwell.1 In 1978 Holland was the first country to adopt capnography as a standard of monitoring during anaesthesia.2 Capnography is useful for much more than checking the position of the endotracheal tube. It provides information about CO2 production, pulmonary perfusion, alveolar ventilation, respiratory patterns and elimination of CO2 from the anaesthesia circuit and ventilator. Thus it gives us a rapid and reliable method to detect life threatening conditions such as malposition of tracheal tubes, ventilatory failure, circulatory failure and defective breathing circuits. The American Society of Anaesthesiologists (ASA) closed claims study showed that 34% of damaging events involve the respiratory system and proposed that 93% of these cases could have been prevented by monitoring with
1. MD, DA, Consultant Anaesthesiologist 2. MD, DA, Consultant Anaesthesiologist Department of Anaesthesiology P.D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 050 Correspond to: Dr J. DMello Ivan Lodge, 2nd floor, 19, DMonte Park Road, Bandra, Mumbai 400 050 E mail:rovanja@vsnl.com

pulse oximetry, capnography or both.3 For this reason the ASA included capnography in its standards for basic monitoring. The Indian Society of Anaesthesiologists has designated capnography as a desirable standard in its Anaesthesia Monitoring Standards Recommended for India with effect from 30th December 1999.4 Terminology Capnography is the graphic display of instantaneous CO2 concentration versus time (Time Capnogram) or expired volume (Volume Capnogram) during a respiratory cycle. Capnograph is the machine that generates a waveform and the capnogram is the actual waveform. Capnometry is the measurement and numerical display of maximum inspiratory and expiratory CO2 concentrations during a respiratory cycle. Capnometer is the device that performs the measurement and displays the reading. However, the capnograph or capnogram, is vastly preferable to a meter or even a fast digital display. In anaesthetic practice breath-by-breath waveform needs to be displayed to permit continuous monitoring and analysis.5 Physics Methods to measure CO2 levels include infrared spectrography, Raman spectrography, mass spectrography, photoacoustic spectrography and chemical colorimetric analysis. The infrared method is most widely used and most cost-effective. Infrared rays are given off by all warm objects and are absorbed by non-elementary gases (i.e. those composed of dissimilar atoms), while certain gases

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absorb particular wavelengths producing absorption bands on the IR electromagnetic spectrum. The intensity of IR radiation projected through a gas mixture containing CO2 is diminished by absorption; this allows the CO2 absorption band to be identified and is proportional to the amount of CO2 in the mixture. Infrared rays have a wavelength greater than 1mm and thus lie beyond the visible spectrum (0.4-0.8mm); CO2 shows strong absorption in the far IR at 4.3mm and so this wavelength in the far IR range is used.6 Raman spectrography uses the principle of Raman scattering for CO2 measurement. The gas sample is aspirated into the analysing chamber, where the sample is illuminated by a high intensity monochromatic argon laser beam. The light is absorbed by molecules, which are then excited to unstable vibrational or rotational energy states (Raman scattering). The Raman scattering signals (Raman light) are then measured. The spectrum of Raman scattering lines can be used to identify all types of molecules in the gas phase including CO2 and inhalational agents.7 The mass spectrograph separates gases and vapours of different molecular weight on the basis of their mass to charge ratios into a spectrum. By analysing the spectrum, the composition and relative abundance of each gas in a sample can be determined. It measures concentration in volumes percent and not partial pressure. Mass spectrometers are quite expensive and too bulky to use at the bedside and are rarely used presently.8 Photoacoustic (PAS) gas measurement is based on the same principle as conventional IR-based gas analysers: the ability of CO2, N2O and anaesthetic agents to absorb IR light. However, they differ in measurement techniques. While infrared spectrography uses optical methods, PAS uses an acoustic technique. However, this method has not gained as much popularity as IR spectrography. The colorimetric method of measuring CO2 employs a chemically treated foam indicator contained in a plastic housing that functions as an endotracheal tube elbow adapter. The colour of the foam adapter changes when it is exposed to exhaled carbon dioxide. The lack of a waveform limits its utility.9 The Effect of Atmospheric Pressure on CO2 A change in atmospheric pressure directly influences the reading of capnographs since CO2 concentration is measured as partial pressure (direct effect). An increase in pressure proportionately increases the number of IR absorbing CO2 molecules and thereby

increases the CO2 signal. A 1% increase in pressure causes a 1% relative increase in the CO2 signal. This effect is eliminated by calibrating the capnograph with a known partial pressure of the CO 2 gas (mmHg=vol%* atmospheric pressure) using a commercially available calibrating gas. Changes in pressure also produce a second effect (alteration of intermolecular forces) exerted by CO2 molecules, which alters the IR absorption. An increase in pressure by 1% results in a relative increase in the signal by 0.5 to 0.8% which can produce a small error. Maximal changes in the atmospheric pressure caused by changes in the weather are of the order of 20 mmHg. This would result in a change in PCO2 of less than 0.50.8 mmHg. Therefore in routine clinical use, corrections for changes in atmospheric pressure are unnecessary. Application of PEEP (positive end expiratory pressure) increases the CO2 reading. A PEEP of 20 cm H2O increases the CO2 reading by 1.5 mmHg. Some units measure the pressure in the sensor and automatically adjust the CO2 reading accordingly.10 The influence of water vapour Erroneous results will occur if water that has a high IR absorbance enters the cell. Water vapour is invariably present in expired air (at 37oC). This condenses at lower room temperature on sampling tube walls. An effective water separation system is required for continuous use. A water trap is used in sidestream analysers to remove water in particulate form before it can enter the analysis cell. The design of the trap relies on gravitational forces to separate drops of water from the gas stream and the trap must be frequently dried out and attention directed to prevent water accumulating. The presence of water vapour also affects the reading since usually the temperature of the patient is 37oC, while that of the instrument cell is, say, 25oC, i.e. a difference of 3kPa (23 mmHg) in PH2O resulting in an overestimate of PCO2 by 0.15% (0.15kPa, 1.13 mmHg).1 Types of Capnographs There are two types of capnographs: Side stream capnographs (Fig.1) and main stream capnographs (Fig.2). In side stream capnography, the CO2 sensor is located in the main unit itself (away from the airway) and a tiny pump aspirates gas samples from the patients airway through a 6 foot long capillary tube into the main unit. The sampling tube is connected to a T-piece inserted at the endotracheal tube or anaesthesia mask connector.

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receiving simultaneous oxygen administration using nasal cannulae. Other advantages of the side stream capnograph are no problems with sterilisation, ease of connection and ease of use when patient is in unusual positions like the prone position.6,11 In the main stream capnograph, a cuvette containing the CO2 sensor is inserted between the breathing circuit and the endotracheal tube. The IR rays traverse the respiratory gases to an IR detector within the cuvette. Thus there is no need for gas sampling and scavenging. Therefore the CO2 analysis is performed within the airway.10 To prevent condensation of water vapour, which can cause falsely high CO2 readings, all main stream sensors are heated above body temperature to about 40oC. The heated sensing head must be kept away from direct contact with the patients skin as it can cause burns. It is relatively heavy and must be supported to prevent endotracheal tube kinking. In addition, the sensors window must be kept clean of mucus and particles to prevent false readings. Despite all these problems, the response time is faster: no gas is subtracted from the breathing circuit, no sampling pumps or other suction devices add complexities to the mechanical system, and there is no uncertainty caused by the rate of gas sampling.12

Figure 1 : Side stream capnograph

Figure 2 : Main stream capnograph

The rate of gas sampling can usually be adjusted from 50 to 500 mlmin1 and at times up to 2 lmin1. The optimal gas flow is considered to be 50-200 mlmin1, which ensures that the capnographs are reliable in both children and adults. If the sampling flow ever exceeds the expired gas flow, contamination from the fresh gas flow source will occur. The sampling gas pump, flow regulator, sampling system including the connector to the sampling port, and water trap constitute multiple sites for gas leak or breakage. Additionally, depending upon the size and length of the sampling tube and the rate of gas flow, a certain delay in gas detection is introduced (CO2 flight time), which can amount to several seconds when the sampling rate is low and the sampling dead space is high (e.g. long tubes). The gas that is withdrawn from the patients often contains anaesthetic gases and so the exhausted gas from the capnograph should be routed to a gas scavenger or retrieved and reinjected through a second tube into the breathing circuit to restore breathing circuit volume.10 The side stream capnographs have a unique advantage: they allow monitoring of spontaneously breathing non intubated subjects, as sampling of the expiratory gases can be obtained from the nasal cavity using nasal adaptors. Further, gases can also be sampled from the nasal cavity during the administration of oxygen using a simple modification of the standard nasal cannulae. This feature enables monitoring of expired CO2 in subjects

Calibration Capnographs must be calibrated periodically, at different intervals in various models as per the manufacturers guidelines, but at least daily.
For accurate measurements capnographs should be calibrated first, zeroing the monitor to room air, and then administering a gas of known CO2 concentration.10 Mainstream capnographs are often equipped with calibration sample cells sealed with mixtures of CO2 and N2. A useful analysis range varies from 0-10 percent (76mmHg) for ETCO2 to an extended range up to 100 mmHg, which may be useful in rare cases of hypoventilation or malignant hyperthermia. As changes in barometric pressure affect PETCO2 measurements, calibration procedures should be performed using the same type of sampling tube as will be used when the analyser is connected to the patient sampling.12

Basic physiology of a capnogram At the end of inspiration, assuming that there is no rebreathing, the airway and the lungs are filled with CO2 -free gases. Carbon dioxide diffuses into the alveoli and equilibrates with the end-alveolar capillary blood (PA CO2 =PcCO2 =40 mmHg). The actual concentration of CO2 in the alveoli is determined by the extent of ventilation and perfusion into the alveoli (V/Q ratio).

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The alveoli with higher ventilation in relation to perfusion (high V/Q alveoli) have lower CO2 compared to alveoli with low V/Q ratio that would have higher CO2. As one moves proximally in the respiratory tract, the concentration of CO2 falls gradually to zero at some point. The volume of CO2-free gas is termed respiratory dead space and here there is no exchange of oxygen (O2) and CO2 between the inspired gases and the blood. As the patient exhales, a CO2 sensor at the mouth will detect no CO2 as the initial gas sampled will be the CO2 free gas from the dead space. As exhalation continues, CO2 concentration rises gradually and reaches a peak as the CO2 rich gases from the alveoli make their way to the CO2 sensing point at the mouth. At the end of exhalation the CO2 concentration decreases to zero (baseline) as the patient commences inhalation of CO2 free gases. The passage of CO2 from the alveoli to the mouth during exhalation and inhalation of CO2 free gases during inspiration gives the characteristic shape to the CO2 curve, which is identical in all humans with healthy lungs. Any deviation from this shape should be investigated to determine a physiological or a pathological cause producing the abnormality.10

Figure 4 : Trend capnogram

Traditionally several phases are distinguished in the capnograph trace (Fig 3). Expiration During the first portion of expiration, during which anatomical and apparatus dead space gas is exhaled there is no CO2 (Phase I). As expiration continues, a short phase of the capnograph is recognised (Phase II), with a rapid S-shaped upstroke on the tracing due to mixing of dead space gas with alveolar gas (Phase III), also called the alveolar plateau represents the CO2 rich gas from the alveoli. In the time capnogram the alveolar plateau lasts for the greater part of the trace, although the expiratory flow is highest at the beginning of expiration and tapers off during the last third of expiratory time. The alveolar plateau almost always has a positive slope, indicating a rising PCO2 and is due to several reasons: The alveolar gas that is sampled later in expiration is in fact richer in CO2 than the early fraction because CO2 excretion from pulmonary capillaries into the alveoli continues at a nearly constant rate during expiration, but CO2 molecules are diluted into a lung volume made progressively smaller by the exhalation process. Slow exhalation, as during an acute asthmatic attack or in patients with chronic obstructive pulmonary disease (COPD), with reduced lung recoil, usually induces a steeper alveolar plateau (Fig.5). If all the alveoli had the same PCO2, then irrespective of the emptying patterns, phase III would be nearly horizontal. However, this ideal situation does not occur, even in normal lungs, which have a wide range of V/Q ratios. Some have a lower V/Q ratio than ideal

The capnographic wave form time capnogram The most commonly used display models PCO2 versus time. A time capnogram (Fig.3) may be recorded at two speeds. When a capnographic trace is displayed on a rapidly scrolling oscilloscope or on fast moving paper (about 7mmsec1), it is possible to recognise several features that may be of diagnostic value. When capnograms are plotted on slow (about 0.7mmsec1) moving paper or trends (Fig.4) of only inspired and ET CO2 values are produced, it is still possible to recognise important clinical information regarding rising or falling concentrations of both inspired and expired CO2.10

Figure 3: Normal time capnogram

A typical time capnogram can be considered as two segments, an inspiratory segment and an expiratory segment and two angles, an alpha and a beta angle.

Figure 5: Slanting and prolongation of expiratory upstroke indicative of obstruction to gas flow caused by a partially obstructed tracheal tube or obstruction in the patients airways (chronic obstructive lung disease or bronchospasm)

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alveoli (under ventilated) resulting in a relatively higher PCO2. The delayed emptying of these alveoli with low V/Q (high PCO2) contributes to the rising slope of phase III.10,13,14 Phase III reaches a peak, usually attained only during the final phase of exhalation, and is called the end tidal partial pressure of CO2 (PETCO2). PETCO2 in the normal individual is usually 2 to 3 mm Hg lower than PaCO2. Chronic pulmonary disease and acute disturbances in V/Q usually widen this difference to several millimeters of mercury. Occasionally PETCO2 may exceed PaCO2. In these situation the variations in alveolar PCO2 (which oscillates between arterial and mixed venous values) may be relatively large, causing the PETCO2 to rise above the arterial value.12 Sometimes, when expiration is prolonged and progresses to a lung volume below closing capacity, expired CO2 concentration may rise sharply at the end of the alveolar plateau. One possible reason for this is that if lung units supplied by airways predisposed to closure, contain alveolar gas with lower PCO2, closure of these airways would allow a greater proportion of CO2 rich gas to reach the upper airway, producing the sharp upswing in CO2 concentration. An alternative hypothesis is that during the course of expiration, well ventilated lung units have a progressive, non-linear upsloping increase in PCO2, whereas that of poorly ventilated (closure prone) units increases in a linear fashion. Therefore, when airway closure occurs, the rate of rise in well-ventilated units predominates, and slope of the capnogram abruptly increases. This portion of the capnogram is occasionally referred to as phase IV12 (Fig3).

end-tidal CO2 will be present (Fig.7). When the respiratory gas flows decrease below the sidestream gas sampling rate, the characteristics of the sampling vary. Instead of sampling a portion of the mainstream flow, the sample may be taken from the respiratory circuit, which is important in the paediatric setting, during low flow anaesthesia, and when interpreting capnograms obtained during very low respiratory rates12 (Fig.8).

Figure 6 : Baseline is elevated due to rebreathing, an incompetent expiratory valve, exhausted absorbent, insufficient fresh gas flow or deliberate addition of CO2 to the fresh gas.

Figure 7: Too low a sampling rate with a side stream capnometer will result in a low peak and, often elevation of the base line

Inspiration After phase III is complete, the descending limb makes an almost right angle turn and rapidly descends to the base line. This represents the inspiratory phase during which the fresh gases (CO2 free gases) are inhaled and CO2 concentration falls rapidly to zero. The segment of the CO2 trace from the beginning of inspiration to the beginning of expiration, which includes the descending limb and the initial part of the horizontal base line is most commonly referred to as phase IV10 (Fig 3).
The capnogram value during inspiration represents the concentration of CO2 in the inspirate and is dependent mostly on the breathing circuit used and inspiratory flow and fresh gas flow values. Rebreathing of dead space volume is often the cause of an inspired level above baseline15 (Fig 6). Exhaustion of the CO2 absorber may also result in elevated inspired PCO2. If there is too low a sampling rate erroneous values for both inspired and

Figure 8:Contamination of expired sample by fresh gas by placing sampling site too near fresh gas inlet or too high a sampling flow rate.

The Alpha angle The angle between phases II and III, which has been referred to as the alpha angle, increases as the slope of phase III increases. Normally it is between 1000 and 1100. The alpha angle is an indirect indication of V/Q status of the lung. Airway obstruction causes an increased slope and a larger angle. Other factors that affect the angle are the response time of the capnograph, sweep speed, and the respiratory cycle time.

The Beta angle The nearly 90 degrees angle between phase III and the descending limb in a time capnogram has been termed as the beta angle. This can be used to assess the extent of rebreathing. During rebreathing, there is an increase in beta angle from the normal 90 degrees. Other factors,

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such as prolonged response time of the capnometer compared to respiratory cycle time of the patient, particularly in children, can produce increase in the beta angle with the elevation of the baseline.10

Volume Capnogram Carbon dioxide concentration when plotted against expired volume during a respiratory cycle is termed as Volume Capnogram. Unlike the Time Capnogram it has only an expiratory segment and no inspiratory segment. Volume capnography (Fig.9) has several advantages over time capnography. First, the volume of CO2 exhaled per breath can be measured. Second, significant changes in the morphology of the expired wave form can be detected in the volume capnogram (e.g. secondary to PEEP) that are not seen in the traditional time capnogram.

The CO2 analyser used in SBT-CO2 tracings are mainstream capnometers, where the cuvette containing the CO2 sensor is inserted between the endotracheal tube and breathing circuit. So, endotracheal intubation is required for plotting an SBT-CO2 curve, whereas a time capnogram does not require intubation to monitor a spontaneously breathing patient. Time capnography can be used to monitor the dynamics of expiration as well as inspiration, whereas the SBT-CO2 curve monitors expiration exclusively.10 Clinical aspects of capnography Capnography provides 3 sources of information: from numbers- PET CO2 values- capnometry, from shapes of capnograms - capnography and from (a-ET) PCO2 differences.10

F Figure 9 : Volume capnogram: shaded area between F and E represent dead space, area enclosed by BCDE is the volume of CO2 exhaled per breath.

Capnometry Various factors result in an increased, decreased or absent PET CO2. However, it is recommended that capnometry be used with capnography as the latter gives diagnostic and therapeutic information and confirms the adequacy of CO2 sampling. Capnography Characteristic abnormal waveforms can help in the diagnosis of underlying clinical or technical abnormalities such as partial airway obstruction, accidental extubation and circuit disconnections, hypermetabolic states etc. This permits early institution of the corrective measures before irreversible damage is done to the patient. Abnormalities should be found by analysing the various phases of the capnogram for individual breaths as well as observing trends over a period of time. Five characteristics should be inspected: height, frequency, rhythm, baseline, and shape.
The effectiveness of therapeutic measures taken can be assessed from the continuous evaluation of the capnogram. For example a patient with bronchospasm will have an improved waveform once bronchodilators are given. Capnography may be the only guide to detect the adequacy of gas sampling from the airways, the presence of leaks in the sampling system, and the malfunction of CO2 measuring system. When there is an adequate sampling of CO2 a good and consistent capnogram, is seen, whereas dilution of expired CO2 by atmospheric air or fresh gas flow results in an abnormal capnogram. PET CO2 as an estimate of PaCO2 Measurements of PETCO2 are a non invasive method of monitoring PaCO2 and hence the ventilatory

Third, dead space can be partitioned into components of interest. Total physiologic dead space (VD PHYS) can therefore be measured, using arterial PCO2 and the Bohr equation, assuming PACO2=PaCO2. Anatomic dead space (VD ANAT, including gas volume within a breathing circuit in which exhaled gas is rebreathed, such as the endotracheal tube, passive humidification device, or Y-piece) can be calculated directly from the volume capnogram (Fig.9). Alveolar dead space is the difference between VD PHYS and VD ANAT, and is related to the difference between alveolar and arterial PCO2. Normally, one can estimate alveolar PCO2 using PETCO2 obtained from the time capnogram as a measure of PACO2. When the alveolar plateau has a significant slope, however, PETCO2 can exceed PaCO2, and average alveolar PCO2 (PAECO2) obtained from the volume capnogram may be a more appropriate measure. However, time capnography is the method most commonly used in clinical practice, as more elaborate equipment is necessary for plotting Single Breath Test CO2 (SBT-CO2) trace. The CO2 analyser has to be designed to operate with the ventilator, which provides a flow signal and a timing pulse. A computer relates the instantaneous CO2 signals to expired volume and an SBTCO2 curve is plotted.

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status of patients. In normal individuals, the (a-ET) PCO2 may vary from 2-5 mmHg. It can vary from patient to patient and is dependent on several factors. It increases with age, pulmonary disorders (emphysema), pulmonary embolism, decreasing cardiac output, hypovolaemia and anaesthesia. It decreases with large tidal volumes and low frequency ventilation. In pregnant women and in infants and smaller children, the (a-ET) PCO2 is lower and reflects Pa CO2. Changes in PET CO2 are regarded as indicative of changes in Pa CO2. The PET CO2 is even more useful if its relationship to Pa CO2 can be established initially by blood gas analysis. Thereafter, changes in Pa CO2 may be assumed to occur in parallel with those in PET CO2 thus avoiding repeated arterial puncture. However, variations in (a-ET)P CO2 during major surgery may be present and caution must be used in the precise prediction of Pa CO2 from PET CO2.10 Clinical applications of capnography CO2 is produced in the body by cellular metabolism, conveyed by the circulatory system to the lungs, excreted by the lungs and transported by the breathing system.5 Therefore, changes in respired CO2 may reflect alterations in metabolism, circulation, respiration, the airway, or breathing system. Normal end expiratory CO2 partial pressure ranges between 35 and 45 mmHg (Figs.10,11).

excessive production of catecholamines, administration of blood or bicarbonate, release of an arterial clamp or tourniquet with reperfusion of ischaemic areas (Fig.12), glucose in the intravenous fluid, parenteral hyperalimentation, and CO2 used to inflate the peritoneal cavity during laparoscopy, the pleural cavity during thoracoscopy or a joint during arthroscopy.

Figure 12 : Release of a tourniquet or unclamping of a major vessel may result in a sudden increase in end-tidal carbon dioxide that gradually returns to normal

Malignant hyperthermia is a hypermetabolic state with a massive increase in CO2 production. The increase occurs early, before the rise in temperature. Early detection of this syndrome is one of the most important reasons for routinely monitoring CO2. Capnography can be monitored for the effectiveness of treatment. CO2 production falls with decreased temperature, increased muscle relaxation, and increased depth of anaesthesia.

Circulation A decrease in end tidal CO2 is seen with a decrease in cardiac output if ventilation remains constant.
Reduced blood flow to the lungs can also result from surgical manipulations of the heart or thoracic vessels, wedging of a pulmonary artery catheter, and pulmonary embolism (thrombus, tumour, gas fat, marrow, or amniotic fluid). A rapid decrease of PET CO2 in the absence of changes in blood pressure, central venous pressure and heart rate indicates an air embolism without systemic hemodynamic consequences. However as the size of air embolism increases, a reduction in output occurs which further decreases PET CO2 (Fig.13,14).

Figure 10: Low end-tidal carbon dioxide with a good alveolar plateau may be the result of hyperventilation or an increase in dead space ventilation

Figure 11:Elevated end-tidal carbon dioxide with good alveolar plateau may be caused by hypoventilation

Metabolism An increase in end-tidal CO2 is a reliable indicator of increased metabolism only in mechanically ventilated patients. In spontaneously breathing patients, PET CO2 may not increase as a result of hyperventilation
Metabolic causes of increases in expired CO2 include increased temperature, shivering, convulsions,
Figure 13:Events that cause an exponential decrease in end tidal CO2 include sudden hypotension, circulatory arrest and pulmonary embolism

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Respiration The main use of the capnographic signal in anaesthesia is the immediate verification of tracheal intubation beyond doubt by the immediate and continuous presence of metabolic CO2 in the expired gas.
CO2 detection of oesophageal placement has some drawbacks and limitations. Bronchospasm, equipment malfunction, application of PEEP or cricoid pressure occluding the tip of the tube can result in failure to detect CO2. With oesophageal intubation, small waveforms may be transiently seen as a result of CO2 that has entered the stomach during mask ventilation or from carbonated beverages or medications. This could give the impression that the tube is correctly placed in the trachea. However, rapidly diminishing concentration and abnormal waveforms will usually differentiate oesophageal from tracheal intubation. End-tidal CO2 can aid in performing a blind oral or nasal intubation. A capnograph is attached to the tracheal tube as it is being inserted into a spontaneously breathing patient and the CO2 wave form and or peak CO2 level used as a guide. As the tube approaches the larynx, the CO2 increases and decreases as it moves away. As the tube is advanced and the tip passes between the vocal cords, a normal capnogram is observed. Capnography can be used to identify needle placement during transtracheal cricothyrotomy. Capnography can be used in conjunction with a jet stylet introducer in cases where the glottic opening cannot be visualised.5 Capnography has also been used to verify tracheal intubation during awake fiberoptic bronchoscopy by attaching the capnograph to the suction connector of the scope. This is especially useful when fiberoptic visualisation is obscured.16 Capnography is used to help in determining proper position and detecting dislodgement of a double lumen bronchial tube. Examining the waveform from each lung during clamping and unclamping procedures can check correct placement. A CO2 monitor is used to monitor respiratory rate of exhaled CO2 in unintubated patients breathing spontaneously. Apnoea or airway obstruction can be detected. If ventilation of the breathing space is inadequate rebreathing will occur and can be detected by a rising inspired CO2 level. Peak CO2 levels correlate more closely with Pa CO2 values than average end tidal levels. Poor correlation is associated with partial airway obstruction

Figure 14 : Small air embolus

During resuscitation, exhaled CO2 is a better guide to the presence of circulation than the electrocardiogram (ECG), pulse, or blood pressure. The effectiveness of resuscitation measures can be gauged by capnography. The capnogram is not susceptible to the mechanical artefacts associated with chest compression, However, if high dose epinephrine or bicarbonate is used, end tidal CO2 is not a good indicator of resuscitation measures. A sudden increase in end tidal CO2 during resuscitation is an early clue that spontaneous cardiac output has been restored. Exhaled CO 2 concentrations are helpful in determining which patients are likely to be successfully resuscitated. The patient is more likely to be resuscitated if the concentration of exhaled CO2 is greater than 10-15 mmHg. Epinephrine injected subcutaneously has been shown to increase the end tidal CO2. One possible explanation is that cardiac output may be increased with additional CO2 being transported to the lungs. Peripheral vasoconstriction might increase central blood volume and pulmonary blood flow. Cardiogenic oscillations (Fig.15) appear as small, regular, tooth like humps at the end of the expiratory phase. They are believed to be due to the contraction and relaxation of the heart and intrathoracic great vessels on the lungs, forcing air in and out. They are usually seen at low respiratory rates and in children.

Figure15 : Cardiogenic oscillations appear as small, regular, tooth like humps at the end of the expiratory phase

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and high respiratory rates. Results may be improved by isolating insufflated O2 from exhaled gases, observing the waveform for normal configuration, and decreasing the O2 flow rate. In mouth breathers, the cannula may be realigned over the mouth or the mouth may be closed. Another major use of capnography has been to determine the correct ventilatory needs (minute ventilation) during controlled ventilation. This use is easily extended to continuous monitoring of spontaneous ventilation and to monitoring of appropriate ventilation during titration of anaesthetic agents that depress ventilation. In partial rebreathing circuits and in low-flow anaesthesia, capnography facilitates the adjustment of fresh gas flow, which is a major determinant of CO2 levels as it may increase minute ventilation. The shape of a partial rebreathing capnogram may vary greatly, depending on the ventilatory frequency and tidal volume. Patients who are partially paralysed with muscle relaxants may make respiratory efforts. This can alert the anaesthesia provider that the muscle relaxant is wearing off. It may occur anywhere in the respiratory cycle (Fig.16). If the depression occurs in the later third of the waveform it is referred to as curare cleft (Fig.17). Capnography can also help while weaning (Fig. 18).

Anaesthetic apparatus Circuit leaks (Fig.19), which decrease the minute volume, are detected by a gradual increase in PET CO2. CO2 monitors detect disconnection instantaneously in paralysed patients. CO2 monitoring gives an early warning of CO2 retention by the patient due to a faulty anaesthetic system or malfunction of valves in circle anaesthetic systems.

Figure 19 : A leak in the sampling line during positive pressure ventilation

A total occlusion or accidental extubation of the endotracheal tube results in an abrupt decrease in PET CO2. Capnography is more valuable than capnometry in detecting partially kinked endotracheal tubes, as distortions in CO2 waveforms (prolonged phase II, steeper phase III, irregular height of the CO2 wave forms) occur earlier than changes in PET CO2. However, there must be at least 50% occlusion of the endotracheal tube to produce changes in PET CO2 or in the CO2 waveforms.10

Figure 16 : Spontaneous respiratory efforts during mechanical ventilation

Figure 17: Curare cleft or notch

Capnography in infants and small children Main stream capnometers are more accurate than side stream capnometers for proximal site PET CO2 measurements but they may cause unacceptable rebreathing. Distal PET CO2 should be used if the weight of the child is < 12 kg, and during the use of partial rebreathing circuits. Recently, Microstream technology (NBP-75, Nellcor Puritan Bennett, Plesanton, CA, USA) has been introduced with an aspiration flow rate of 30mlmin1. but with rapid response time which takes away the disadvantages of conventional capnographs. It provides accurate PET CO2 measurements, minimises distortions in CO2 waveforms and reduces the chance of secretions being drawn into the system.10 Recommended educational material on Capnography Dr. Bhavani-Shankar Kodali, a well published expert on the subject of capnography, has created the Capnography website : URL: http://www.capnography.com/.17 The site provides a complete review of end tidal carbon dioxide monitoring during anaesthesia and intensive care. In addition, his Web site provides animated graphics that are not possible to produce in a textbook and can greatly facilitate learning.

Figure 18 : Return to spontaneous ventilation

Monitoring PET CO2 can be used successfully to determine Pa CO2 levels during high frequency jet ventilation (HFJV) by delivering a single breath of large tidal volume and measuring PET CO2 during a brief interruption of HFJV.10

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INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2002 9. Mollgaard K. Acoustic gas measurement. Biomedical instrumentation and Technology 1989; 23:495-7 10. www.capnography.com. Website produced by Bhavani Shankar Kodali 11. Carbon dioxide monitors. Health Devices 1986; 15:255-85 12. Moon RE, Camporesi EM. Respiratory Monitoring in. In: Anaesthesia Vol I 5th ed. Miller RD (ed). New York: Churchill Livingstone, 2000:1255-95 13. Bhavani Shankar K, Moseley H, Kumar AY et al. Capnometry and anaesthesia. Review article. Can J Anaesth 1992; 39: 6: 517-32 14. Bhavani Shankar K, Kumar AY, Moseley H et al. Terminology and the current limitations of time capnography. J Clin Monit 1995;11:175-82 15. Yasodananda Kumar A, Bhavani Shankar K, Moseley HSL et al. Inspiratory valve malfunction in a circle system: pitfalls in capnography. Can J Anaesth 1992;39:997-9 16. Wolf LH, Gravenstein D. Capnography during fiberoptic bronchoscopy to verify tracheal intubation. Anesth Analg 1997;85:701-3 17. Eisenach JC. Review of Web site. Capnography. Anesthesiology; 2001;95:1049.

References
1. Adams AP Capnography and pulse oximetry, Atkinson RS, Adams AP (ed). Recent Advances in Anaesthesia and Analgesia; 1989,155-175. 2. Advisory Report on Anaesthesiology, Part 1: Recent developments in Anaesthesiology, Committee of the Health Council of the Netherlands, 1978. 3. Tinker JH, Dull DL, Caplan RA. Role of monitoring devices in prevention of anesthetic mishaps. A closed claims analysis. Anesthesiology 1989;71:541-546. 4. www.isa-india.org/. Website of the Indian Society of Anaesthesiologists. 2000 5. Dorsch JA, Dorsch SE (ed) Understanding Anaesthesia Equipment, Gas monitoring. 1999, 679-753 6. Kalenda Z. Mastering Infrared Capnograhy. The Netherlands: Kerckebosch- Zeist, 1989 7. TremperKK, Barker SJ. Fundamental principles of monitoring instrumentation. In: Anaesthesia Vol I 3rd ed. Miller RD (ed). New York: Churchill Livingstone, 1990:957-99 8. Raemer DB, Philip JH. Monitoring anesthetic and respiratory gses. In: Blitt CE (Ed). Monitoring in Anesthesia and Critical Care Medicine. 2nd edition. New York: Churchill Livingstone, 1990:373-86.

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